ESPEN指南：外科臨床營(yíng)養(yǎng)

ESPEN將養(yǎng)分整合入患者整體治理避開(kāi)長(zhǎng)時(shí)間術(shù)前禁食術(shù)后盡早重建立經(jīng)口喂養(yǎng)一旦養(yǎng)分風(fēng)險(xiǎn)變得明顯，早期開(kāi)頭養(yǎng)分療法將養(yǎng)分整合入患者整體治理避開(kāi)長(zhǎng)時(shí)間術(shù)前禁食術(shù)后盡早重建立經(jīng)口喂養(yǎng)一旦養(yǎng)分風(fēng)險(xiǎn)變得明顯，早期開(kāi)頭養(yǎng)分療法代謝把握，例如血糖削減加重應(yīng)激相關(guān)分解代謝或影響胃腸功能的因素縮短用于術(shù)后呼吸機(jī)治理的麻醉藥物使用時(shí)間早期活動(dòng)以促進(jìn)蛋白質(zhì)合成和肌肉功能恢復(fù)縮寫(xiě)縮寫(xiě)B(tài)M：生物醫(yī)學(xué)終點(diǎn)GPP：良好實(shí)踐要點(diǎn)。依據(jù)指南制定小組臨床閱歷推舉的最正確實(shí)踐方法。HE：醫(yī)療衛(wèi)生經(jīng)濟(jì)終點(diǎn)IE：整合傳統(tǒng)終點(diǎn)與患者報(bào)告終點(diǎn)QL：生活質(zhì)量TF：管飼者在麻醉前兩個(gè)小時(shí)應(yīng)喝清流質(zhì)。麻醉前六小時(shí)前應(yīng)允許進(jìn)食固體食物〔BM、者在麻醉前兩個(gè)小時(shí)應(yīng)喝清流質(zhì)。麻醉前六小時(shí)前應(yīng)允許進(jìn)食固體食物〔BM、IE、QL〕。推舉等級(jí)：A，高度共識(shí)〔97%同意〕時(shí)間，對(duì)大手術(shù)患者可考慮術(shù)前使用碳水化合物〔0，BM、HE〕。推舉等級(jí)：A/B，高度共識(shí)〔100%同意〕在完成過(guò)程中由工作小組依據(jù)最薈萃分析下調(diào)等級(jí)〔100%同意〕〔BM、IE〕。推舉等級(jí)：A，高度共識(shí)〔90%同意〕等級(jí)：GPP，高度共識(shí)〔100%同意〕〔同意〕GPP，高度共識(shí)〔100%同意〕5507GPP，高度共識(shí)〔92%同意〕假設(shè)能量和養(yǎng)分需求不能僅通過(guò)經(jīng)口和腸道攝入滿足〔＜50%〕超禁忌證如腸梗阻〔A〕，應(yīng)盡快賜予腸外養(yǎng)分〔BM〕。推舉等級(jí)：GPP/A，高度共識(shí)〔100%同意〕〔三腔袋或藥房配制〔BM、HE〕。推舉等級(jí)：B，高度共識(shí)〔100%同意〕等級(jí)：GPP，高度共識(shí)〔100%同意〕PN脈補(bǔ)充谷氨酰胺〔0，BM、B，共識(shí)〔76%同意〕，在完成過(guò)程中由工作小組依據(jù)最近的PRCT〔100%同意〕僅對(duì)因腸內(nèi)喂養(yǎng)缺乏而需要腸外養(yǎng)分的患者應(yīng)考慮術(shù)后腸外養(yǎng)分包括使用ω-3脂肪酸〔BM、HE〕。推舉等級(jí)：B，大多數(shù)同意〔65%同意〕對(duì)承受癌癥大手術(shù)養(yǎng)分不良的患者應(yīng)在圍手術(shù)期或至少術(shù)后使用富含免疫養(yǎng)分HE〕。目前沒(méi)有明確的證據(jù)說(shuō)明在圍手術(shù)期使用這些富含免疫養(yǎng)分素的配方優(yōu)于標(biāo)準(zhǔn)的口服養(yǎng)分補(bǔ)充劑。推舉等級(jí)：B/0，共識(shí)〔89%同意〕〔A〕，即使手術(shù)，包括那些癌癥，必需推遲〔BM〕7～14A/0，高度共識(shí)〔95%同意〕/腸內(nèi)途徑識(shí)〔100%同意〕服養(yǎng)分補(bǔ)充劑，不管他們的養(yǎng)分狀況如何。推舉等級(jí)：GPP，共識(shí)〔86%同意〕術(shù)前應(yīng)對(duì)全部養(yǎng)分不良的癌癥患者和進(jìn)展腹部大手術(shù)的高風(fēng)險(xiǎn)患者賜予口服養(yǎng)分等級(jí)：A，高度共識(shí)〔97%同意〕術(shù)前腸內(nèi)養(yǎng)分/口服養(yǎng)分補(bǔ)充劑應(yīng)在入院前使用，以避開(kāi)不必要的住院治療和降低院內(nèi)感染的風(fēng)險(xiǎn)〕EN7～14同意〕對(duì)不能早期開(kāi)頭經(jīng)口養(yǎng)分?jǐn)z入、經(jīng)口攝入缺乏〔＜50%〕7的患者〔A，BM〕嚴(yán)峻創(chuàng)傷包括顱腦損傷的患者〔A，BM〕手術(shù)時(shí)有明顯養(yǎng)分不良的患者〔A，BM，GPP〕推舉等級(jí)：A/GPP，高度共識(shí)〔97%同意〕一般不建議使用廚房制備的膳食〔勻漿膳〕TF。推舉等級(jí)：GPP，高度共識(shí)〔94%同意〕至于養(yǎng)分不良患者的特別方面，對(duì)全部承受上消化道和胰腺大手術(shù)患者進(jìn)展TFB，高度共識(shí)〔95%同意〕同意〕10～由于腸道耐受性有限，5～7GPP，共識(shí)〔85%同意〕TF〔＞4〕，如重癥顱腦損傷，建議經(jīng)皮置管〔如經(jīng)皮內(nèi)鏡下胃造口—PEG〕。推舉等級(jí)：GPP，高度共識(shí)〔94%同意〕等級(jí)：GPP，高度共識(shí)〔97%同意〕TF。推舉等級(jí)：GPP，高度共識(shí)〔100%同意〕建議。推舉等級(jí)：GPP，高度共識(shí)〔100%同意〕識(shí)〔97%同意〕24內(nèi)養(yǎng)分。推舉等級(jí)：GPP，高度共識(shí)〔100%同意〕等級(jí)：GPP，高度共識(shí)〔93%同意〕高度共識(shí)〔100%同意〕高度共識(shí)〔100%同意〕高度共識(shí)〔100%同意〕/針刺導(dǎo)管空腸造口術(shù)。推舉等級(jí)：0，共識(shí)〔87%同意〕〔94%同意〕ClinNutr.2023Jun;36(3):623-650.ESPENguideline:Clinicalnutritioninsurgery.n,a,i,ir,k,oLjungqvistO,LoboDN,MartindaleR,WaitzbergDL,BischoffSC,SingerP.KlinikumSt.Georg,Leipzig,Germany;SanRaffaeleHospital,Milan,Italy;McGillUniversity,MontrealGeneralHospital,Montreal,Canada;FujitaHealthUniversity,Toyoake,Aichi,Japan;CentreHospitalierUniversitaireVaudois(CHUV),Lausanne,Switzerland;StanleyDudrick”sMemorialHospital,Skawina,Krakau,Poland;Universita“LaSapienza“Roma,Roma,Italy;OrebroUniversity,Orebro,Sweden;NottinghamUniversityHospitalsandUniversityofNottingham,Queen”sMedicalCentre,Nottingham,UK;OregonHealth&ScienceUniversity,Portland,OR,USA;UniversityofSaoPaulo,SaoPaulo,Brazil;UniversitatHohenheim,Stuttgart,Germany;RabinMedicalCenter,BeilinsonHospital,PetahTikva,Israel.Earlyoralfeedingisthepreferredmodeofnutritionforsurgicalpatients.Avoidanceofanynutritionaltherapybearstheriskofunderfeedingduringthepostoperativecourseaftermajorsurgery.Consideringthatmalnutritionandunderfeedingareriskfactorsforpostoperativecomplications,earlyenteralfeedingisespeciallyrelevantforanysurgicalpatientatnutritionalrisk,especiallyforthoseundergoinguppergastrointestinalsurgery.ThefocusofthisguidelineistocovernutritionalaspectsoftheEnhancedRecoveryAfterSurgery(ERAS)conceptandthespecialnutritionalneedsofpatientsundergoingmajorsurgery,e.g.forcancer,andofthosedevelopingseverecomplicationsdespitebestperioperativecare.Fromametabolicandnutritionalpointofview,thekeyaspectsofperioperativecareinclude:integrationofnutritionintotheoverallmanagementofthepatientavoidanceoflongperiodsofpreoperativefastingre-establishmentoforalfeedingasearlyaspossibleaftersurgerystartofnutritionaltherapyearly,assoonasanutritionalriskbecomesapparentmetaboliccontrole.g.ofbloodglucoseBM:BM:biomedicalendpointsGPP:Goodpracticepoints.RecommendedbestpracticebasedontheclinicalexperienceoftheguidelinedevelopmentgroupHE:healthcareeconomyendpointIE:integrationofclassicalandpatient-reportedendpointsQL:qualityoflifeTF:tubefeedingreductionoffactorswhichexacerbatestress-relatedcatabolismorimpairgastrointestinalfunctionminimizedtimeonparalyticagentsforventilatormanagementinthepostoperativeperiodearlymobilisationtofacilitateproteinsynthesisandmusclefunctionTheguidelinepresents37recommendationsforclinicalpractice.1.1.Preoperativefastingfrommidnightisunnecessaryinmostpatients.PatientsPatientsundergoingsurgery,whoareconsideredtohavenospecificriskofofaspiration,shalldrinkclearfluidsuntiltwohoursbeforeanaesthesia.SolidsSolidsshallbealloweduntilsixhoursbeforeanaesthesia(BM,IE,QL).GradeGradeofrecommendationA-strongconsensus(97%agreement)2.Inordertoreduceperioperativediscomfortincludinganxietyoralpreoperativecarbohydratetreatment(insteadofovernightfasting)thenightbeforeandtwohoursbeforesurgeryshouldbeadministered(B)(QL).Toimpactpostoperativeinsulinresistanceandhospitallengthofstay,preoperativecarbohydratescanbeconsideredinpatientsundergoingmajorsurgery(0)(BM,HE).ConsensusConference:GradeofrecommendationA/B-strongconsensus(100%agreement)-downgradedbytheworkinggroupduringthefinalizationprocessaccordingtotheveryrecentmeta-analysis(with100%agreementwithintheworkinggroupmembers)Ingeneral,oralnutritionalintakeshallbecontinuedaftersurgerywithoutinterruption(BM,IE).GradeofrecommendationA-strongconsensus(90%agreement)Itisrecommendedtoadaptoralintakeaccordingtoindividualtoleranceandtothetypeofsurgerycarriedoutwithspecialcautiontoelderlypatients.GradeofrecommendationGPP-strongconsensus(100%agreement)Oralintake,includingclearliquids,shallbeinitiatedwithinhoursaftersurgeryinmostpatients.GradeofrecommendationA-strongconsensus(100%agreement)Itisrecommendedtoassessthenutritionalstatusbeforeandaftermajorsurgery.GradeofrecommendationGPP-strongconsensus(100%agreement)Perioperativenutritionaltherapyisindicatedinpatientswithmalnutritionandthoseatnutritionalrisk.Perioperativenutritionaltherapyshouldalsobeinitiated,ifitisanticipatedthatthepatientwillbeunabletoeatformorethanfivedaysperioperatively.Itisalsoindicatedinpatientsexpectedtohaveloworalintakeandwhocannotmaintainabove50%ofrecommendedintakeformorethansevendays.Inthesesituations,itisrecommendedtoinitiatenutritionaltherapy(preferablybytheenteralroute-ONS-TF)withoutdelay.GradeofrecommendationGPP-strongconsensus(92%agreement)Iftheenergyandnutrientrequirementscannotbemetbyoralandenteralintakealone(<50%ofcaloricrequirement)formorethansevendays,acombinationofenteralandparenteralnutritionisrecommended(GPP).Parenteralnutritionshallbeadministeredassoonaspossibleifnutritiontherapyisindicatedandthereisacontraindicationforenteralnutrition,suchasinintestinalobstruction(A)(BM).GradeofrecommendationGPP/A-strongconsensus(100%agreement)Foradministrationofparenteralnutritionanall-in-one(three-chamberbagorpharmacyprepared)shouldbepreferredinsteadofmultibottlesystem(BM,HE).GradeofrecommendationB-strongconsensus(100%agreement)Standardisedoperatingprocedures(SOP)fornutritionalsupportarerecommendedtosecureaneffectivenutritionalsupporttherapy.GradeofrecommendationGPP-strongconsensus(100%agreement)Parenteralglutaminesupplementationmaybeconsideredinpatientswhocannotbefedadequatelyenterallyand,therefore,requireexclusivePN(0)(BM,HE).ConsensusConference:GradeofrecommendationB-consensus(76%agreement)-downgradedbytheworkinggroupduringthefinalizationprocessaccordingtotherecentPRCT(with100%agreementwithintheworkinggroupmembers).Postoperativeparenteralnutritionincludingomega-3-fattyacidsshouldbeconsideredonlyinpatientswhocannotbeadequatelyfedenterallyand,therefore,requireparenteralnutrition(BM,HE).GradeofrecommendationB-majorityagreement(65%agreement)Peri-oratleastpostoperativeadministrationofspecificformulaenrichedwithimmunonutrients(arginine,omega-3-fattyacids,ribonucleotides)shouldbegiveninmalnourishedpatientsundergoingmajorcancersurgery(B)(BM,HE).Thereiscurrentlynoclearevidencefortheuseoftheseformulaeenrichedwithimmunonutrientsvs.standardoralnutritionalsupplementsexclusivelyinthepreoperativeperiod.GradeofrecommendationB/0-consensus(89%agreement)Patientswithseverenutritionalriskshallreceivenutritionaltherapypriortomajorsurgery(A)evenifoperationsincludingthoseforcancerhavetobedelayed(BM).Aperiodof7-14daysmaybeappropriate.GradeofrecommendationA/0-strongconsensus(95%agreement)Wheneverfeasible,theoral/enteralrouteshallbepreferred(A)(BM,HE,QL).GradeofrecommendationA-strongconsensus(100%agreement)Whenpatientsdonotmeettheirenergyneedsfromnormalfooditisrecommendedtoencouragethesepatientstotakeoralnutritionalsupplementsduringthepreoperativeperiodunrelatedtotheirnutritionalstatus.GradeofrecommendationGPP-consensus(86%agreement)Preoperatively,oralnutritionalsupplementsshallbegiventoallmalnourishedcancerandhigh-riskpatientsundergoingmajorabdominalsurgery(BM,HE).Aspecialgroupofhigh-riskpatientsaretheelderlypeoplewithsarcopenia.GradeofrecommendationA-strongconsensus(97%agreement)Immunemodulatingoralnutritionalsupplementsincludingarginine,omega-3fattyacidsandnucleotidescanbepreferred(0)(BM,HE)andadministeredforfivetosevendayspreoperatively(GPP).Gradeofrecommendation0/GPP-majorityagreement,64%agreementPreoperativeenteralnutrition/oralnutritionalsupplementsshouldpreferablybeadministeredpriortohospitaladmissiontoavoidunnecessaryhospitalizationandtolowertheriskofnosocomialinfections(BM,HE,QL).GradeofrecommendationGPP-strongconsensus(91%agreement)PreoperativePNshallbeadministeredonlyinpatientswithmalnutritionorseverenutritionalriskwhereenergyrequirementcannotbeadequatelymetbyEN(A)(BM).Aperiodof7-14daysisrecommended.GradeofrecommendationA/0-strongconsensus(100%agreement)Earlytubefeeding(within24h)shallbeinitiatedinpatientsinwhomearlyoralnutritioncannotbestarted,andinwhomoralintakewillbeinadequate(<50%)formorethan7days.Specialriskgroupsare:patientsundergoingmajorheadandneckorgastrointestinalsurgeryforcancer(A)(BM)patientswithseveretraumaincludingbraininjury(A)(BM)patientswithobviousmalnutritionatthetimeofsurgery(A)(BM)(GPP).GradeofrecommendationA/GPP-strongconsensus(97%agreement)Inmostpatients,astandardwholeproteinformulaisappropriate.Fortechnicalreasonswithtubeclotggingandtheriskofinfectiontheuseofkitchen-made(blenderized)dietsfortubefeedingisnotrecommendedingeneral.GradeofrecommendationGPP-strongconsensus(94%agreement)Withspecialregardtomalnourishedpatients,placementofanasojejunaltube(NJ)orneedlecatheterjejunostomy(NCJ)shouldbeconsideredforallcandidatesfortubefeedingundergoingmajoruppergastrointestinalandpancreaticsurgery(BM).GradeofrecommendationB-strongconsensus(95%agreement)Iftubefeedingisindicated,itshallbeinitiatedwithin24haftersurgery(BM).GradeofrecommendationA-strongconsensus(91%agreement)Itisrecommendedtostarttubefeedingwithalowflowrate(e.g.10-max.20ml/h)andtoincreasethefeedingratecarefullyandindividuallyduetolimitedintestinaltolerance.Thetimetoreachthetargetintakecanbeverydifferent,andmaytakefivetosevendays.GradeofrecommendationGPP-consensus(85%agreement)IflongtermTF(>4weeks)isnecessary,e.g.insevereheadinjury,placementofapercutaneoustube(e.g.percutaneousendoscopicgastrostomy-PEG)isrecommended.GradeofrecommendationGPP-strongconsensus(94%agreement)Regularreassessmentofnutritionalstatusduringthestayinhospitaland,ifnecessary,continuationofnutritiontherapyincludingqualifieddietarycounsellingafterdischarge,isadvisedforpatientswhohavereceivednutritiontherapyperioperativelyandstilldonotcoverappropriatelytheirenergyrequirementsviatheoralroute.GradeofrecommendationGPP-strongconsensus(97%agreement)Malnutritionisamajorfactorinfluencingoutcomeaftertransplantation,somonitoringofthenutritionalstatusisrecommended.Inmalnutrition,additionaloralnutritionalsupplementsoreventubefeedingisadvised.GradeofrecommendationGPP-strongconsensus(100%agreement)Regularassessmentofnutritionalstatusandqualifieddietarycounsellingshallberequiredwhilemonitoringpatientsonthewaitinglistbeforetransplantation.GradeofrecommendationGPP-strongconsensus(100%agreement)Recommendationsforthelivingdonoran